CHAPTER 3 _________________ THE VERTEBRAL SUBLUXATION IN CHIROPRACTIC PRACTICE Chapter Outline I. Overview II. History and Chiropractic Examination III. Instrumentation IV. Radiographic and Other Imaging V. Clinical Impression and Assessment VI. Reassessment and Outcomes Assessment VII. Modes of Adjustive Care VIII. Duration of Care for Correction of Vertebral Subluxation IX. Chiropractic Care for Children X. Patient Safety XI. Professional Development 65 I. Overview This component of the International Chiropractors Association protocols and guidelines represents the incorporation of a fully compatible clinical practice document developed by a parallel guidelines committee. The focus of this section is on the subluxation, the core of chiropractic clinical responsibility. In many respects, this chapter is a summary document that addresses in an efficient and concentrated format the essentials of subluxation detection and care. This section is the intellectual product of an independent panel of chiropractic researchers, educators and practitioners, the Council on Chiropractic Practice (CCP), consisting of William Ralph Boone, Ph.D., DC, Terry A. Rondberg, DC, Harold G. McCoy, DC, Emmanuel T. Akporiaye, Ph.D., Robert Blanks, Ph.D., Patrick Gentempo, DC, John J. Gerhardt, M.D., Veronica Gutierrez, DC, Jonathan Hatch, Esq., Jay Holder, DC, Carol James (consumer representative), Matthew McCoy, DC, Stephen F. Renner, DC and Steven Shochat, DC. This panel was chaired by Christopher Kent, DC, who also served as a member of the ICA Guidelines Committee. The CCP effort came to fruition in 1998, and this text has been incorporated into the ICA protocols and guidelines with the permission of the CCP and upon vote of the ICA Board of Directors. These guidelines were specifically compiled according to strict evidenced-based guidelines development procedures. Evidence-based clinical practice is defined as “The conscientious, explicit and judicious use of the current evidence in making decisions about the care of individual patients…(it) is not restricted to randomized trials and meta-analysis. It involves tracking down the best external evidence with which to answer our clinical questions.” (Sackett, DL. Editorial: Evidence Based Medicine, Spine, 1998; 23(10):1085. RATINGS AND CATEGORIES OF EVIDENCE RATINGS Established: Accepted as appropriate for use in chiropractic practice for the indications and applications stated. Investigational: Further study is warranted. Evidence is equivocal, or insufficient to justify a rating of “established”. Inappropriate: Insufficient favorable evidence exists to support the use of this procedure in chiropractic practice. 66 CATEGORIES OF EVIDENCE E. Expert opinion based on clinical experience, basic scientific rationale, and/or individual case studies. Where appropriate, this category includes legal opinion. L. Literature support in the form of reliability and validity studies, observational studies, “pre-post” studies, and/or multiple case studies. Where appropriate, this category includes case law. C. Controlled studies, including randomized and non-randomized clinical trials of acceptable quality. The entire following text represents the unaltered work of the CCP panel. The International Chiropractors Association wishes to express sincere appreciation for the efforts of those who participated in this important endeavor. ICA wishes to highlight the full compatibility of the findings of this group with those of the ICA Guidelines Committee. That these parallel yet independent efforts developed such highly consistent findings is an indication of the fundamental validity of the respective conclusions and practice recommendations. History and Chiropractic Examination II CASE HISTORY RECOMMENDATION A thorough case history should precede the initiation of chiropractic care. The elements of this history should include general information, reason for seeking chiropractic care, onset and duration of any symptomatic problem, family history, past health history, occupational history, and social history. Rating: Established Evidence: E, L Commentary The purpose of the case history is to elicit information which might reveal salient points concerning the patient's spinal and general health that lead the chiropractor to elect appropriate examination procedures. The case history may provide information which will assist the chiropractor in determining the safety and appropriateness of chiropractic care as well as the nature of additional analytical procedures to be performed. History taking is considered a key element of quality patient care necessary for effective doctor- patient communication and improved patient health outcomes.(1-4) Verbal, nonverbal and cognitive assessment are also included in the patient history. The chiropractic case history should emphasize eliciting information relevant to the etiology and clinical manifestations of vertebral subluxation. 67 CHIROPRACTIC EXAMINATION RECOMMENDATION The initial chiropractic examination shall include a case history and an assessment for the presence of vertebral subluxation, which, if present, is to be noted with regard to location and character. A review of systems may be conducted at the discretion of the practitioner, consistent with individual training and applicable state laws. Reassessments may be conducted periodically throughout a course of chiropractic care to assess patient progress. Such reassessments typically emphasize re-examination of findings which were positive on the previous examination, although need not be limited to same. Reassessment is also indicated in the case of trauma or change in the clinical status of a patient. Rating: Established Evidence: E, L Commentary The term subluxation has a long history in the healing arts literature. It may be used differently outside of the chiropractic profession. The earliest non-chiropractic English definition is attributed to Randall Holme in 1668. Holme defined subluxation as "a dislocation or putting out of joynt"(5) In medical literature, subluxation often refers to an osseous disrelationship which is less than a dislocation.(6) However, B.J. Palmer, the developer of chiropractic, hypothesized that the "vertebral subluxation" was unique from the medical use of the term "subluxation" in that it also interfered with the transmission of neurological information independent of what has come to be recognized as the action potential. Since this component has yet to be identified in a quantitative sense, practitioners currently assess the presence and correction of vertebral subluxation through parameters which measure its other components.(7) These may include some type of vertebral biomechanical abnormality,(8-14) soft tissue insult of the spinal cord and/or associated structures(15-49) and some form of neurological dysfunction involving the synapse separate from the transmission of neurological information referred to by Palmer.(50-57) As noted, chiropractic definitions of subluxation include a neurological component. In this regard, Lantz (58) stated "common to all concepts of subluxation are some form of kinesiologic[al...sic] dysfunction and some form of neurologic[al...sic] involvement." In a recently adopted position paper, The Association of Chiropractic Colleges accepted a definition of subluxation as follows: "A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health."(59) The case history and examination are means of acquiring information pertinent to the location and analysis of subluxation. This information is primarily used to characterize subluxation regarding its presence, location, duration, and type. Additionally, the information gained through 68 analysis guides the practitioner to ascertain which chiropractic techniques best suit the patient to effect correction of the condition. Data collected during the patient's initial consultation and examination, pertaining to the health history and presenting concerns, thus supports the decision-making process of the practitioner. This information, relayed by the practitioner to the patient, further serves to incorporate the patient into the decision-making process regarding chiropractic care. Elements of the Examination History Important elements of the case history include previous and present social and occupational events revealed by the patient; unusual sensations, moods or actions relative to the patient, with dates of occurrence and duration; previous chiropractic and non-chiropractic intervention; and other factors. The case history usually includes the following: 1. Patient clinical profile. A. Age. B. Gender. C. Occupation. D. Other information germane to the presenting complaint, if any. 2. Primary reasons for seeking chiropractic care. A. Primary reason. B. Secondary reason. C. Other factors contributing to the primary and secondary reasons. 3. Chief complaint, if one exists. This may include onset and duration of symptoms as well as their subjective and objective characteristics, and location, as well as aggravating or relieving factors. A Trauma, by etiology, when possible. B. Chief complaint. C. Characteristics of chief complaint. D. Intensity/frequency/location, radiation/onset/duration. E. Aggravating/arresting factors. F. Previous interventions (including chiropractic care), treatments, medications, surgery. G. Quality of pain, if present. H. Sleeping position and sleep patterns. 69 4. Family